Central sleep apnea in a treatment-resistant migraine patient: a case report

INTRODUCTION: Patients with migraine, who suffer from sleep apnea, whether obstructive or central, might lead to treatment-resistant headaches. In this study, we have reported a 42-year-old man with a confirmed treatment-resistant migraine headaches and hemiplegic attacks, who was referred to our sleep clinic for evaluation of sleep breathing problems. CASE REPORT: The patient had recurrent attacks of migraine headaches with hemiplegic attacks. The patient had headache in the past 15 years that based on ICHD-3 criteria classified as hemiplegic migraine. The severity and recurrences of headache and hemiplegic attacks gradually increased for 1 year, before he referred to our sleep clinic that led to several hospital admissions. He had been evaluated for other causes of headache; it seems that other headache causes have been ruled out. Treatment with medication was not effective to abolish symptoms. He had a history of occasional snoring and his wife had witnessed multiple episodes of apnea and frequent awakening by feeling suffocation at sleep. The patient abused methadone since 2 years ago. Based on the findings in polysomnography, the patient was diagnosed with central sleep apneas. After titration, bi-level positive airway pressurespontaneous timed mode (BiPAP-ST) was prescribed for the patient. In one year of using BiPAPST the central apneas events were controlled, while the frequency of migraine headache decreased remarkably to one attack per month and the hemiplegic attacks resolved without any other change in his medical treatment or methadone use. DISCUSSION: Patients with chronic headaches usually have insufficient sleep, sleep apnea and poor sleep quality, change in sleep architecture can be an introduced trigger for headache, furthermore in opium abusers, symptoms got intensified. Resolve exacerbating factors can reduce headache recurrence and severity. CONCLUSION: It is important to screen high-risk patients for possible sleep disorders such as apnea, especially in treatment resistant migraine cases. Also, we should assess analgesics or opioids abuses and a complete history for other risk factors of central sleep apnea.